Troops bring back sand disease

Troops Being Treated For Leishmaniasis
By Lisa Burgess
Stars and Stripes
European Edition

March 20, 2004, 

ARLINGTON, Va. — About 500 soldiers who have served in Iraq have been diagnosed with a skin disease caused by sand flies in the largest outbreak of leishmaniasis faced by the U.S. military since World War II, according to Defense Department doctors.  

The disease is caused by parasites transmitted via sand fly saliva, and comes in three forms: cutaneous, affecting the skin; mucosal, affecting the mouth, nose and throat; and visceral, affecting internal organs, which can be fatal if untreated.

All but two of the cases diagnosed so far have been the cutaneous form and all but three of those were contracted in Iraq, according to Dr. Alan Magill, a specialist in infectious diseases at Walter Reed Army Institute of Research in Maryland.

The remaining three cases of cutaneous “leish” were contracted by U.S. servicemembers deployed to Afghanistan, Magill said in a Thursday interview, as were the two cases of visceral leishmaniasis.

The last time the Pentagon doctors had to cope with a leishmaniasis outbreak was 1943, when about 1,000 U.S. soldiers stationed in what is now Iran came down with the cutaneous version.

Significant numbers of U.S. troops also were deployed to countries where leishmaniasis is a risk during Operation Desert Storm.

But that conflict produced just 32 confirmed cases — probably because almost all the servicemembers were deployed in November 1990 and were sent home before peak sand fly season, which runs from late March to late September.

“We got lucky,” Magill said.

When it came time for Operation Iraqi Freedom, however, DOD’s core group of about a dozen “leish” specialists were certain that luck would not hold.

“We were sending thousands of troops to an area of known disease,” Magill said, under conditions ripe for maximum sand fly exposure.

The troops were entering Iraq just as the sand flies were beginning to multiply. Insect control programs were limited to the sprays and salves soldiers could apply on the move. And the troops were living “in the rough,” bedding down atop vehicles or directly on the ground.

“So it was absolutely no surprise” when hundreds of troops were affected, Magill said.

Experts from the 520th Theater Army Medical Laboratory began testing sand flies for leishmaniasis in Iraq in June.

“We found an enormous amount were infected,” Magill said. “We knew right then and there we were going to see lots of cases.”

But it wasn’t until late August that the first case was confirmed, Magill said — in part because cutaneous leishmaniasis has a two- to eight-week incubation period; and also because samples from all suspect lesions have to be sent back to Walter Reed for evaluation.

By October, “we knew there were scores of cases” among Iraq-deployed troops, Magill said. “And late November was about the time everything really ramped up.”

Military experts believe the numbers will drop in the second Iraq rotation, Magill said.

“I’m pretty sure we’ll see fewer cases this time around,” he said. “Troops are moving around less,” with less makeshift billeting, and commanders have had time to implement rodent-control programs that in turn help control the sand flies.

Magill and his colleagues have also worked hard to educate both medical personnel and troops, traveling both in Iraq and to bases in the United States to spread the word.

“There certainly has been an attempt to get the message out,” Magill said. “Ninety percent of the battle is just getting people thinking about it.”

Meanwhile, to handle the current influx of patients, DOD officials are opening a second treatment center at Brooke Army Medical Center in San Antonio that will be authorized by the Food and Drug Administration to administer Pentostam, the only drug used to treat the cutaneous version.

Brooke will open to servicemembers “within weeks” for leishmaniasis and will join Walter Reed as the only facilities in the United States with the FDA certifications to administer the investigational drug.

Cutaneous patients receive Pentostam intravenously for 10 to 20 days. But only the more serious cases require the often-uncomfortable regime, Magill said.

Mild cases can be treated with liquid nitrogen, which freezes the lesions and kills the parasites. Doctors can also carefully apply heat to stop the infestations, Magill said.

But the best news is that cutaneous leishmaniasis heals by itself in time, even without treatment, Magill said.

“I don’t care how bad [the lesions] look,” he said. “It may take a year more, but they will all heal.”

About 200 of the diagnosed servicemembers have decided to let the lesions heal, despite the military’s offer of medical treatment, he said.

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